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Registration Form: Energy Healing with Annelies
Please submit this form before your first session to help us save time on the day
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Name
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Address
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Phone number
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Date of Birth
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Emergency contactÂ
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Emergency contact phone number
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If you are under 18, a signed consent letter from your parent or guardian is required before your first session. Has the parent or guardian given consent?
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No (please supply a copy before appointment)
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If you are pregnant, or within 10 days postpartum. Please provide a written consent from your primary healthcare provider before the session
Written consent form my primary healthcare provider received (please supply a copy)
Written consent from my primary healthcare provider requested (please supply a copy before appointment)
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What has led you to explore healing support right now?
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Are you currently on any prescribed medication? If yes, please provide details
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Name of your primary healthcare provider
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Contact number of your primary healthcare provider
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